Improving Patient Outcomes with Minimally Invasive Surgery

Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.



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Vol. 8 No. 45


Have you checked out Virtual MISS 2020? It’s going on now—but if you missed sessions or live “Best of” panels, don’t worry—all live content is also archived for your convenience. It’s a fantastic way to get your CME in right from your home and with superior content that historically has only been available to those willing to travel to it! If you want to view the live events of this past week, including Tuesday 6/9 Best of Colon and Thursday 6/11 is Best of Hernia, click here!

Additionally, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Tim Miller, President of ASER, who opined on Virtual MISS 2020, key MISS enhanced recovery takeaways, COVID-19’s impact on anesthesia and enhanced recovery, standards for opioids, and preop COVID testing.

This week I speak with Dr. Francesco Rubino, a world-renowned surgical expert on the pathophysiology of diabetes and obesity, and the anti-diabetes effect of bariatric procedures, and MISS 2020 Faculty. Dr. Rubino and I discuss the 2020 MISS and the power of a quality meeting in-person and online, current COVID publications and the process of peer review, the recent surgeon recommendations from the Diabetes Surgery Summit COVID-19 webinar, and COVID’s impact on several facets of healthcare in the United Kingdom.

I’d like to thank Dr. Rubino for taking the time to speak with me for MISS E-News! We again include the most current COVID-related best practices resources in our new MISS E- News Resource Center. Check them out, and especially don’t miss the Annals of Surgery Brief Clinical Report and the call to volunteer via the ACS Operation Giving Back.

**Don’t forget to link to the Virtual MISS 2020 Symposium here!**

Stay safe and check back next week for more!


Colleen Hutchinson


Interview with Dr. Francesco Rubino

Colleen: With MISS 2020 approaching and as we look to celebrate its 20 th anniversary, what do you anticipate for it being conducted as an online meeting and what do you think will be most valuable to attendees online?
Dr. Francesco Rubino: I always felt that the MISS meeting was a nice mix of excellent lectures by leading experts and an opportunity to network in a friendly and relaxed environment. We will definitely miss the latter component this year and it is sad. But I am sure we can still appreciate the great content provided via online presentations and panel discussions and there will be no lack of opportunities for interaction and questions. We will hopefully meet again in person, colleagues and friends next year.

Colleen: On Twitter, you recently raised an important issue on current COVID publications and peer review. Specifically, you tweeted: According to the New York Times, greater than 10,000 scientific articles on COVID-19 have been published since January. Of them 3,500 are "preprints" with no peer-review. Pre-prints share time-sensitive data, which is useful in a pandemic. The issue is: how much bad science is there in 3,500 papers? How would you answer your own question?
Dr. Francesco Rubino: The peer-review process to assess the validity of scientific papers is far from perfect and has numerous limitations. In fact, the recent retraction of articles at two major medical journals shows that inaccurate papers or even cases of research misconduct can pass peer review at the most prestigious journals. That said, it is safe to assume that the risk of bad science being promoted through scientific articles is even greater when papers are rushed through and posted online on repositories without any form of assessment whatsoever. While bad science can cause damage anytime, the damage is exponentially greater during a pandemic.

Colleen: What were the main recommendations shared in your Diabetes Surgery Summit-COVID- 19 Webinar, Recommendations for Bariatric/Metabolic Surgery in Times of Coronavirus and Beyond? Especially in terms of criteria for prioritization?
Dr. Francesco Rubino: Given that widespread misconceptions, weight bias and the stigma of bariatric surgery have not gone away with the pandemic, we were concerned that these issues could be an even greater barrier in times of limited capacity of elective services. On the other hand, unlike for other surgical disciplines, there were no mechanisms to define prioritization in bariatric/metabolic surgery based on disease burden and relative urgency of treatment, despite the fact that our patients can be affected by a variety of conditions with significantly different prognosis. The DSS-COVID-19 edition was organized to address these issues. We made a number of recommendations to assist clinicians, hospital managers and policy makers in making their decisions in these complicated times. The two main messages from the DSS-COVID-19 edition can be summarized as such: 1. Obesity and diabetes can increase the risk of severe COVID-19. This, however, should not be a reason to further delay bariatric/metabolic surgery. As soon as it is safe to restart elective operations, patients with severe diabetes or obesity have all the reason and right to be among those with prioritized access to surgical therapy. In their case, not only can surgery treat a progressive and potentially lethal disease, but it can also reduce risk of severe COVID-19 during predictable future outbreaks in the course of this pandemic; 2. The second important message was directed to our colleague surgeons to ensure they can appropriately prioritize their patients using the same principles in use in other surgical disciplines. In fact, in general surgery prioritization is based on relative urgency of treatment and this is based on whether the disease may cause harm if not treated within 3 months. Using the expertise of a multidisciplinary panel of experts, the DSS has identified prognostic factors of morbidity and mortality from diabetes, obesity or other conditions that are amenable to treatment by bariatric/metabolic surgery. The relative urgency of bariatric/metabolic surgery was then assessed based on such prognostic factors and the available evidence that surgery can be effective at improving prognosis in specific conditions.

After publication of our DSS recommendations, we have seen an initial polarization in our field, with some surgeons endorsing the DSS principles and others suggesting that we should instead prioritize patients with less burden of disease. I am particularly concerned that the latter approach may seem intuitive or desirable to reduce the risk of in-hospital infection in patients at plausibly greater risk of severe COVID-19, but in reality, it is a misconceived idea for many reasons. For one, this strategy would de-prioritize patients with greatest need, for whom delaying surgery will certainly cause harm from progression of their disease. It would be, in my opinion, both medically and ethically questionable if we tried to use very limited resources to expedite treatment of patients who would receive no harm if their surgery is postponed. Furthermore, this strategy would undermine the chances of our patients to have access to treatment when competing for limited space with other surgical specialties where surgeons traditionally use prioritization criteria based on objective urgency of treatment. Any patient with pain, or any level of risk of progression of disease will be – rightly – felt to have greater priority. Finally, I believe the exit from lockdown and the re-start of elective surgical services will be a defining moment for our field. If we, as a community of bariatric/metabolic surgeons, can show the severity of diseases that we treat with our procedures and the urgency these diseases represent, we will raise awareness of the lifesaving implications of bariatric/metabolic surgery. On the contrary, pushing to expedite treatment in patients with no risk of harm from delay will reinforce the widespread misconception that bariatric/metabolic surgery is optional, or a treatment with the same priority level of a cosmetic procedure. The next few months will be critical, and we bariatric/metabolic surgeons have a huge responsibility: the way we respond to this pandemic could either promote the image of bariatric surgery as an evidence-based, lifesaving treatment or reinforce stereotypes and prejudice. It is up to us to rise to the challenge.

Colleen: In past issues, we have talked about necessity being the mother of invention, and COVID’s impact on several facets of healthcare. What is COVID-19’s impact in the UK comparatively speaking on the following—in a few words:

  • The profession of surgery in the UK moving forward: The pandemic will accelerate a transformation of our profession as it makes innovation in care and training all the more important. This is true in the UK and elsewhere.
  • Residents’ and fellows’ learning and training in the UK: We will face a period where training junior surgeons will be more challenging. In the next few months we will have to compete for limited space, and this has several repercussions. Inevitably, there will be less OR capacity for each discipline and a yet a need to operate as many cases as possible, especially during the window of time between successive peaks of the pandemic. This means there will be less time to train fellows and residents in the OR compared to normal. Perhaps this will be the time where platforms for e-learning and surgical simulation could play a greater role than in the past, at least until we return to a more physiologic inpatient capacity.
  • Doctors’ ability to provide ongoing quality general patient care to those with chronic disease—for example, those with diabetes: We are just starting to realize the inevitable consequences of the clash of three pandemics: COVID-19, diabetes, and obesity. The COVID-19 pandemic is also a reminder - by comparison – of the fact that we have not been able to “flatten the curve” of obesity and diabetes over 4+ decades. There will have to be some reckoning after the COVID-19 pandemic as to what went wrong with our prevention and treatment strategies of obesity and diabetes. It will be clear that we must come up with entirely new ideas to approach these issues. This is not a bad thing and may actually be a unique opportunity to reverse the tide.
  • Medical conferences and other in-person educational events: We are realizing three things in this pandemic: 1. We were having too many meetings annually, with not all of them strictly necessary or useful; 2. Many good meetings can be attended remotely via teleconferencing platforms without detriment to the learning experience; 3. There are still a few meetings that cannot be replaced by teleconferencing and require physical presence, networking, and appropriate time for exchange of knowledge. By the end of this pandemic, we will probably learn how to recognize which meeting is which.

Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery?
Dr. Francesco Rubino: YES.

Colleen: Do you think that laparoscopy should be used in patients with COVID-19?
Dr. Francesco Rubino: YES, with appropriate cautions. I am sure there is a way to mitigate risk for staff and surgeons while maintaining the benefits of laparoscopy for patients.

Colleen: Do you think that negative pressure operating rooms are critical for surgery in patients with COVID-19?
Dr. Francesco Rubino: I am not sure we have evidence to say if that is absolutely necessary. We should use common sense and mitigate risk of contagion as we do for any type of aerosol-generating procedure.


MISS E-News COVID Resource Center: Link to these!

Annals of Surgery Brief Clinical Report (Online only): Social Media Responses to Elective Surgery Cancellations in the Wake of COVID-19

ACS Operation Giving Back: COVID-19 Medical Workforce Volunteers Needed.
If you are willing to volunteer in any capacity, please complete the following survey:

ASMBS Webinar: COVID-19 Town Hall Q&A: Restarting Surgery – Issues to Consider In Prioritizing Cases

SAGES Guidelines: SAGES primer for taking care of yourself during and after the COVID-19 crisis

IBC COVID-19 Webinar Tuesday, June 16: Back to the Future.
Register here:



Suggested Readings


Article: Safety of adjustable gastric band conversion surgery: a systematic review and meta-analysis of the leak rate in 1- and 2-stage procedures. Zadeh J, Le C, Ben-David K.
Surgery for Obesity and Related Diseases 16 (2020) 437–444

Dr. Jaime Ponce: This is the latest meta-analysis on the band conversion surgery data, which is the most common revisional bariatric procedure. This review analyzes the differences in safety outcomes between 1- and 2- stage conversions in 25 publications. The overall results showed that there is no significant difference in the leak rate between 1- and 2- stage approaches, and this may be different to initial analysis showing increased rates. The conversions and the ability to create a stomach stapled pouch dealing with the scar tissue has improved and in my opinion the learning curve has proven to be a major factor to decrease complications in these difficult cases.
The paper conclusions add the fact that there is a trend in the data that suggests a safety advantage for 1-stage when converting to bypass and 2- stage when converting to sleeve gastrectomy. As they also suggested and I agree, band erosions should be done in 2-stage as there is not enough data and there could be a potential for adverse events.



Article: The new weight-loss drugs, lorcaserin and phentermine-topiramate: slim pickings? Woloshin S, Schwartz LM. JAMA Intern Med. 2014 Apr;174(4):615-9.

Dr. Steve Nissen: This review in JAMA Internal Medicine highlights the limited efficacy of weight loss drugs.



Vol. 8 No. 44


We are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Jo Buyske, President and CEO of the American Board of Surgery. This week I speak with Dr. Timothy Miller, MISS 2020 Faculty and President of the American Society for Enhanced Recovery, from Duke University School of Medicine. Dr. Miller and I discuss what Virtual MISS 2020 will be like, what MISS enhanced recovery takeaways will be, COVID-19’s impact on anesthesia and enhanced recovery, the standards for enhanced recovery regarding opioids, and preoperative testing for COVID. We end with the ASMBS application for a focused practice designation in metabolic and bariatric surgery. I’d like to thank Dr. Miller for taking the time to speak with me for MISS E-News.

We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. Check them out, and especially don’t miss the new ACS Patient Surgery Toolkit—a new post-COVID-19 resource to help you and your hospital address patient concerns.

**Don’t forget to link to the Virtual MISS 2020 Symposium here!**

Stay safe and check back next week for more!


Colleen Hutchinson


Interview with Dr. Timothy Miller

Colleen: With MISS 2020 approaching and as we look to celebrate its 20 th anniversary, what do you anticipate for it being conducted as an online meeting and what do you think will be the most important takeaways from MISS2020 regarding enhanced recovery for surgeons to learn and understand?
Dr. Miller: Regarding MISS being online this year, I think we have all learned over the last few months that online learning can be highly effective, and that it has a number of advantages in terms of being able to bring together clinicians from different locations. But it is different, of course, and we all miss the social aspect of meetings and the connections that we can make at them. I think the important message about enhanced recovery is that it continues to evolve and it is not a case of “job done.” I really enjoy the multidisciplinary collaborations with enhanced recovery and look forward to continuing to advance best practices as our population ages.

Colleen: As President of ASER, you are uniquely positioned to update readers on what’s new in enhanced recovery. Can you summarize current updates for MIS surgeons that have recently taken place and will move the needle forward on best practices in patient care?
Dr. Miller: Enhanced recovery is continuing to evolve. Two broad areas that have seen recent emphasis are preoptimization and the use of big data to answer questions about best practices. First, preoptimization of nutrition, anemia, and prehabilitation are increasingly being incorporated into pathways. Second, two examples of new information from research that has been recently published using big data are the importance of avoiding hypotension (MAP <65) and an increase in respiratory complications with the use of gabapentinoids, especially in the elderly.

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Miller: We have changed a number of practices to enable us to deliver safe anesthesia and surgery during the COVID-19 pandemic. We have a dedicated COVID team each day to manage both COVID airways and surgical cases using appropriate PPE. All team members were trained in our simulation unit. All surgical preoperative consultations are performed with telemedicine, and the preoperative clinic also arranges for all patients to get a COVID-19 test within 72 hours of surgery.

Colleen: What standards are being or have been implemented for enhanced recovery regarding opioids?
Dr. Miller: All protocols and consensus statements about enhanced recovery include opioid minimization and multimodal/regional analgesia as one of the key components in enhanced recovery pathways. Opioid-free anesthesia is feasible for some pathways, although more evidence is needed about long-term outcomes, in particular chronic opioid use and chronic pain. Having a “standard of care” around opioid use is difficult as every pathway is dependent on surgical, patient, and institutional factors. Instead, I suggest that every institution needs to develop their own pathways with the key principles of patient education about pain expectations and opioid minimization.

Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery?
Dr. Miller: It’s a complex question and depends on many factors, including the prevalence of COVIID-19 and the availability of tests. That being said, I think best practice currently is to test all patients. This gives staff peace of mind and enables them to carry out their jobs without concerns about becoming infected. It is also reassuring for patients. We test all patients within 72 hours of surgery at Duke, and also have POC tests in preoperative and the emergency department for level 1-4 cases.


MISS E-News COVID Resource Center: Link to these!

ACS: New Patient Surgery Toolkit! Preparing to Have Surgery During the Time of COVID-19

SAGES Coronavirus Global Surgical Collaborative (CVGSC) Initiative & Summary

ASMBS Webinar: Independent/Community Practices: Surviving COVID-19

IFSO on COVID-19 article in Obesity Surgery: IFSO Recommendations for Metabolic and Bariatric Surgery During the COVID-19 Pandemic  
ACS COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures
IBC Webinar: Emergency Hernia Surgery in the Era of COVID-19 and Severe Obesity

Journal of the American College of Surgeons Article: Ethics in the Time of Coronavirus: Recommendations in the COVID-19 Pandemic

And a reply to above article:
Journal of the American College of Surgeons Article: Challenges and Ethical Considerations for Trainees and Attending Physicians During the COVID-19 Pandemic


Suggested Readings


Article: Bariatric surgery-induced cardiac and lipidomic changes in obesity-related heart failure with preserved ejection fraction. Mikhalkova D, Holman SR, Jiang H, Saghir M, Novak E, Coggan AR, O’Connor R, Bashir A, Jamal A, Ory DS, Schaffer JE, Eagon JC, Peterson LR. Obesity 2018; 26(2):284-290.

Dr. Tammy Kindel: This article, as mentioned at the 2020 MISS meeting, reports on a small cohort of patients with heart failure with preserved ejection fraction examined echocardiographic measurements, lipid cardiac and liver deposition, and heart failure related symptoms. The first published report on heart failure with preserved ejection fraction patients undergoing bariatric surgery, the authors found a significant improvement in heart failure symptoms, reverse detrimental cardiac remodeling, and improved cardiac relaxation, a hallmark of HFpEF. Although small in sample size, the ability to impact HFpEF related cardiac function and symptoms given the current lack of successful pharmacotherapy in HFpEF is an important step forward in metabolic surgery.



Article: Millennium Generation Poses New Implications for Surgical Resident Education. Wall J. Source: American College of Surgeons Resources in Surgical Education.

Dr. Robin Blackstone: Dr. Wall illustrates the effect of culture on training different generations of surgeon trainees. The expectations of life and work are different and important aspects as well as how residents will learn. This is a great mind-opening short article for anyone who is in the midst of training.



Vol. 8 No. 43


We are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Steven Wexner on COVID and colorectal surgery, the ACS COVID communications resources, his recent COVID publication, and what the new normal will be for elective surgery. This week I interviewed Dr. Jo Buyske, President and CEO of the American Board of Surgery. It’s an interesting time to talk with Dr. Buyske, given that she oversees the ABS and is leading the charge to innovate during these challenging times. Under her leadership, the ABS 2020 General Surgery Qualifying Exam will now be offered virtually as a web-based, live-proctored, at-home examination in July. We discuss COVID-19’s impact on the ABS, its major impact on the profession of surgery moving forward, its impact on residents’ and fellows’ learning and training, the future of surgical training and specialization, and the role of the non-specialist general surgeon in today’s age. We end with the ASMBS application for a focused practice designation in metabolic and bariatric surgery. I’d like to thank Dr. Buyske for taking this time to discuss these topics and more for the MISS E-News.

We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. This week’s resources include the JACS article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic, ACS post-COVID economic survival strategies guide, SAGES new free webinar on thriving in surgical practice post-COVID, IBC Channel’s latest COVID webinar, ASMBS’s new webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout, and the ACS new Entering Resident Readiness Assessment (ACS ERRA) program—a great tool post-COVID-19 to ascertain thepreparedness of entering residents and identify gaps.

**Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here!**
Stay safe and check back next week for more!


Colleen Hutchinson


Interview with Dr. Jo Buyske—President & CEO of the American Board of Surgery

Colleen: In past issues, we have talked about necessity being the mother of invention, and new uses of technology such as telemedicine and virtual reality creating more touch points with patients and practice management support during this pandemic.
Now the American Board of Surgery (ABS) has innovated and the 2020 General Surgery Qualifying Exam will be administered virtually as a web-based, live-proctored, at-home examination.
What is COVID-19’s impact on the ABS, and what do you see as its major impact on the profession of surgery moving forward?

Dr. Buyske: The ABS, like so many other companies, has been tremendously impacted by the pandemic. Really all arms of our organization, including office operations, our core work of exam delivery, and the governance functions of the ABS moved quickly to comply with travel bans, shelter in place orders, and CDC guidelines against gatherings. Our office went to 100% work from home on March 17 th . That has been nearly seamless for our surgeon constituents, since we are still answering phones and emails, but it has been a huge culture change for the office. They have done incredibly well at staying productive in an unstable environment.

To our candidates, I’m sure the biggest changes have been the impact on our oral (certifying) exams and written (qualifying) exams. We cancelled general surgery certifying exams in April and June, and the vascular surgery certifying exam in May. We immediately offered all of those disappointed candidates first choice of exam dates for next year’s exam so they could be assured that they would stay on some sort of career timeline, but we also rapidly implemented a video-based oral exam as a small, proof of principle pilot. On May 19 and 20 we delivered the first pilot to 17 people. It was a highly resourced exam, with three examiners and a staffer for each set of candidates. No exam had to be cancelled or invalidated, and we had a pass rate that was consistent with historic norms. A post-exam survey showed a very high degree of satisfaction from the candidates. We will repeat the pilot in a near identical model with a larger group of people on June 2 and 3. After that we will need to pause, address lessons learned, and figure out what we are going to do with the 2000 or so candidates who need to be certified in the upcoming academic year.

Regarding the written exam, our exam centers were struggling with capacity issues due to social distancing requirements that varied from state to state. We did not want our candidates to be subjected to cancelled reservations or any kind of flux, and we were also reluctant to be responsible for people having to either travel or to gather in a testing center. We used a vendor that we already use for the in-training exam and the continuous certification exam, and they helped us quickly convert from the traditional, 8-hour, 1-day exam at a testing center to a 2-day, at-home, remote proctored secure exam. We felt strongly that that was the best thing for our surgeon candidates.

I think that from a leadership point of view, we have grossly underemployed video technology. From our exams to telehealth to virtual meetings, it appears that the world of surgery and healthcare rolls on without airplane flights, days away from work, travel, hotels, and meals. I do think something has been lost by losing the face to face, but it has been incredibly instructive to move so abruptly to virtual interactions, and in many ways we will not go back. This public health crisis accelerated needed change.

What is COVID-19’s impact on residents’ and fellows’ learning and training?

Dr. Buyske: I have to say that that remains to be seen. We know that surgical trainees spent less time in the hospital on surgical services. Residents were kept at home in bullpens, or clean teams, or they were quarantined, or they were sick. The surgical census in hospitals dropped dramatically, so there were fewer cases and fewer consults as well. The overall clinical exposure, across all surgical specialties and all years of training, is significantly diminished.

That being said, this is a once in a lifetime opportunity for residents to really step up to leadership and crisis management, participate in surge capacity planning, manage scarce resources, and be creative with technology. They’ve had to take responsibility for their own learning with meetings and conferences cancelled. It has been a remarkable event, and I’m proud of the way they have stepped up to the plate.

Colleen: What’s the future of surgical training? Will it be 2 to 3 years of general experience and then 2 to 3 years specialty training such as foregut, colorectal, hepato-pancreato-biliary, and bariatric?

Dr. Buyske: I’m not sure I am smart enough to know the future. There are a lot of successful models for training surgeons all over the world, and some of them are as you describe, and produce very good surgeons. At the moment we are focused on acquisition of skills and knowledge, and less on measuring months of training. We are in the last month of a feasibility study for Entrustable Professional Activities (EPA), which would be a new paradigm in formative resident assessment, culminating in summative decisions. It requires multiple microassessments by multiple individuals at different points in time. As is so often the case, the whole is greater than the sum of the parts. The power of EPAs lies in the multiple assessments. This requires a change in thinking on the part of both the trainees and the trainers. Nevertheless, the ABS board of directors voted to march forward with writing the entire portfolio of EPAs that would encompass general surgery training, and to start to implement it as the tool of advancement in training in 2023.

Right now, using our Flexibility in Training (FIT) option, a few trainees have shortened their training. Through FIT, a resident can customize up to 12 months of the last 3 years of training, which in some cases can then count towards fellowship. So modular training is possible…it just isn’t our current focus.

Colleen: The Journal of Surgical Research just published a new article, “Underrepresented in Surgery: (Lack of) Diversity in Academic Surgery Faculty.
”Will this paper help move the needle?

Dr. Buyske: For topics like this one we must be relentless in focus. Keeping the subject in view by publishing, reporting, and documenting is a critical tool in the toolbox to rectifying this dysfunctional situation. Education and awareness are paths out of darkness. We also need to reexamine the metrics we use for advancement. The homogeneity of those descriptors needs to be evaluated. How helpful is it to have 20 people who came up through academic institutions, did a fellowship, work with residents, and have 200-plus publications serving on the same committee? Those are remarkable accomplishments and should be recognized, but bringing other skills and experience to the table is essential to being the best profession we can be.

Colleen: Is there a role for non-specialist general surgeons anymore?

Dr. Buyske: Absolutely, and I think that COVID has shown that. Surgeons were going back to core skills during the peak of this wave of the pandemic. Specialists were doing ICU care, MIS surgeons were doing open cases, and everyone was learning about ventilator management and PPE. The generalist became a valuable commodity. As surgeons were pulled into areas outside their field of specialty or expertise, someone still needed to manage the acute cases. It was very interesting and telling. We cannot afford to play taps for the general surgeon.

Colleen: Can you share your thoughts on the new ABS special designation for bariatric surgery? Will there be board certification for bariatric surgery in the near future? Will there by a special designation for MIS as well?

Dr. Buyske: I am very pleased that the ASMBS applied for a focused practice designation in metabolic and bariatric surgery. The application had to be vetted first through what used to be our Advanced Surgical Education Committee, then the full board of directors of the ABS, then a committee of the American Board of Medical Specialties (ABMS), and then the full board of the ABMS. It is not an easy process. Now we are working on operationalizing that process, including developing the first exam and eligibility criteria. We know that people who do large volume bariatric surgery and focus their practice in general have better outcomes, so this was a good place to start. Several other specialty groups have expressed interest, but at the moment we have no other active designations in the pipeline.


MISS E-News COVID Resource Center: Link to these!

ACS: New Approaches to Educating Surgeons of the Present and Future: Determine the Decision-Making Skills of New Residents with ACS Entering Resident Readiness Assessment (ACS ERRA)

SAGES Free Webinar: Finding the Opportunities: Lessons from COVID and How We Live and Thrive as Surgeons
SAGES’ Reimagining the Practice of Surgery Taskforce’s free webinar on ways innovative leadership can promote healthier approaches to life and work by transforming surgical practice. Access here:

ASMBS New Webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout
Register here:

Journal of the American College of Surgeons Article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic
Full-text article available online:

IFSO on COVID-19: "Enhancing Bariatric Patient Experience During COVID 19"
Register here:

ACS: Economic Survival Strategies in the COVID World: A Guide from the ACS Practice Protection Committee

IBC Webinar: Covid-19 & the Healthcare Professional: Thinking Outside the Box


Suggested Readings


Article: Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery (INPRESS): A Randomized Clinical Trial. Futier et al. JAMA. 2017 Oct 10;318(14):1346-1357

Dr. Tim Miller: The INPRESS trial was one of the first interventional studies aimed at individualizing perioperative blood pressure management. The study showed a reduction in complications in the intervention group that first had their fluid status optimized, followed by inclusion of a vasopressor to maintain blood pressure within 10% of baseline. This trial adds to the increasing evidence that even short duration of hypotension perioperatively, usually defined as a mean BP <65 mmHg, is associated with myocardial and kidney injury.



Article: Effects of Bariatric Surgery on Cardiovascular Function. Ashrafian H, le Roux CW, Darzi A, Athanasiou T. Circulation 2008; 118:2091-2102.

Dr. Tammy Kindel: This review article highlights the complex interplay between obesity, obesity-associated comorbidities and heart failure development. Bariatric surgery through multiple mechanisms, including a reduction in system inflammation and adipokines as well as best treatment of obesity-associated comorbidities, results in improved cardiac function and reduction in heart failure symptoms. The contribution of the entero-cardiac axis to heart failure improvement after bariatric surgery is explored, including literature supporting the role of glucagon-like peptide-1.



Vol. 8 No. 42


We are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. Last week we gave you key insights from MISS 2020 Hernia Program Co-Director Guy Voeller and Colon Program Co-Director Brad Davis on how COVID’s impact on their hernia and colon surgery practices, how they are coping, and what restarting will look like. This week I spoke with Steven Wexner on COVID and colorectal surgery, the ACS COVID communications strategies, resources, and effectiveness, his recent COVID publication in Colorectal Disease, and what the new normal will be for elective surgery. We also discuss whether all patients should be tested for COVID-19 prior to surgery, and if laparoscopy should be used in patients with COVID-19.

We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. This week’s resources include the ACS Post-COVID-19 Readiness Checklist for Resuming Surgery, SAGES summary on the impact of the COVID- 19 Pandemic on the conduct of surgical research, ASGE’s services guidance document for resuming GI endoscopy and operations post-COVID, General Surgery News article on COVID-care billing, IBC Channel’s webinar on COVID implications in obesity, diabetes, metabolic & cancer surgery, and more.

We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here.
Stay safe and check back next week for more!


Colleen Hutchinson

Interview with Dr. Steven Wexner

What changes that have developed during COVID do you think will persist? How can surgeons improve patient care by using these changes?
Dr. Steven Wexner: First and foremost is telehealth. I think absolutely, no doubt whatsoever patients are enjoying the benefits of telehealth, including that they don't have to take excessive time off to come to a health appointment. International and out of state patients don't have to take days off to fly to see us just for a preliminary visit. Even local patients, if they only live a few hours away, have a major time commitment, which with telehealth is greatly improved. They don't have to take the day off to come for a 30-minute visit; they can just take 30 minutes off and be done with their visit. That's a tremendous convenience for patients and it's a service that I hope is not going to be contingent upon whether regulations allow us. Because the obstacle prior to this time was not our unwillingness to do it, but that
we were very limited in the types of systems we could use and the electronic systems and platforms that were permitted because of HIPAA and documentation You couldn't just pick up your phone and use FaceTime or Google Duo or Doximity. Now because of this crisis, suddenly many virtual platforms are now eligible. To be determined is whether or not Medicare and insurance companies will continue to pay for health visits conducted via telehealth. Because if they don't pay a reasonable level, it will not be widely used,


Colleen: As an American College of Surgeons (ACS) Regent, can you tell us about the development, implementation and impact of the ACS’s extensive educational efforts including COVID-related guidelines, resources, your interviews, and the twice-weekly Bulletin: ACS COVID-19 Newsletter?
Dr. Steven Wexner: Absolutely. I think the collective effort of David Hoyt as our Executive Director, Valerie Rusch as our President, Beth Sutton and Scott Levin as our Chair and Vice  Chairs of the Board of Regents, respectively, and the rest of us Regents immediately realized that fellows and members and the public were in dire need of communication during this unprecedented crisis. So we very quickly put together a communications group with the goal of rapidly providing easy to find highly relevant information. We designed the newsletter under the direction of Cori Ashford, who just a few months earlier took the job as the director of communications at the ACS, and we put this newsletter together. Different people assumed different aspects of what to do. Ken Sharp from Vanderbilt along with Lew Flint from
the ACS worked on constantly culling and disseminating the information. The health care policy and advocacy team led by Christian Shalgian, Frank Opelka, and Patrick Bailey provided constant critical information from the government, payers, and other regulatory bodies. Different people made different contributions to this unique effort; I suggested that I could do video interviews.

I am doing video interviews with various doctors from around the world as well as ACS leaders, other surgical leaders, non-surgeon leaders, international colleagues, and surgeons who have been stricken with and fortunately recovered from Covid-19 to make sure that I have two to three videos per issue. The actual interviews have been written and are also going to be published in American Surgeon, so they'll be referenceable.
With all of these efforts, we've gotten tremendous traction. Typically, in a week, we'll get anywhere from 10 to 11 million impressions on Twitter for what we're doing, and the videos are currently viewed by more than 50,000 people each week. The newsletter has been greatly helpful to members, and moving forward, we are transitioning to a once a week Tuesday-only bulletin, which will no longer be strictly COVID19 in content. We are starting to expand what we're doing, with information for fellows and patients and the public beyond COVID19. We'll keep the same editorial board, but we're broadening the net of what we'll include, so my videos might include non-COVID19 related topics of interest. Similar broader coverage will be true for scientific studies, education, advocacy and health policy, and all other topics.


Colleen: Can you tell readers findings in your journal article “COVID‐19: Impact on Colorectal Surgery” in Colorectal Disease?
Dr. Steven Wexner: We found that there is a striking lesson to be learned from pressurized intraperitoneal aerosol chemotherapy (PIPAC) to use for MIS in the COVID-19 era. Specifically, just like PIPEC, we must ensure that the chemotherapy isn't inadvertently coming in contact with personnel in the room. If there are COVID-19 virus particles in the peritoneal cavity, we want to also make sure that the staff are very protected. We want to ensure that if we are performing laparoscopy or robotics, we have really good seals upon systems without any gas leak anywhere and that filters are used to desufflate. Of course,
there are a lot of lessons to be learned about safe laparoscopy and similarly there are lessons about the advisability of negative pressure operating rooms, which not every facility has—but if there's the capability to convert rooms to do so. It's protection of both the patient and of healthcare workers. If an operating room being used for a COVID-19 patient is not a negative pressure operating room, the staff must ensure that nobody but the staff anesthetist is in the room during intubation, that that person as an N95 mask and full PPE and is appropriately protected, and that everyone stays out of the room after intubation for some period of time. There are currently various debates about how long that period of time should be. Basically one must adapt—things like sign-in and time-out have to be adapted in the COVID-19 patient.


Colleen: What are some of the most difficult clinical challenges you are facing as a colorectal surgeon right now because of the virus?
Dr. Steven Wexner: There are two fronts. One issue is the reluctance of patients to come back and have surgery or their colonoscopy—patients have not been coming in for screening and followup colonoscopy and other things, so disease is delayed in treatment. We don't yet know how much of a problem that presents. I don't think it's going to be a huge problem because the delay wasn't years, but rather weeks to months. Nonetheless, I think that moving forward, we're going to find that we need to stay current with screening because of those screening and surveillance opportunities we missed during the pandemic. The second challenge is patients coming back to hospitals. Even though there are safety protocols in place, such as COVID-19 testing, proper PPE and masks, no visitors, and physical distancing, patients are not necessarily comfortable yet coming back into the hospital. Probably the biggest challenge is patients feeling comfortable that we're taking the necessary steps to protect them. COVID-19 may be a lot like HIV disease or 9/11 in that each event induced certain changes in the way we live; we are not going back to pre-COVID days, as we did not go back to pre-HIV or pre-9/11 days. Universal precautions and security measures are now permanent features of our world; the same will be true of COVID-19.


Colleen: What will the new normal be for elective surgery?
Dr. Steven Wexner: I think that unfortunately for the foreseeable future, patients are not going to have the support systems they're accustomed to having in the hospital. They're not going to have family and friends come and visit. A major factor that contributes to recovery is mental well-being and attitude, and knowing (as a patient) that the people about whom you care, people who love you, are there with you is an important facet of recovery and mental well-being. Right now patients are sort of having to do it on their own because of these various restrictions. Hopefully one day those restrictions will relax, and we will get back to a point where people can have family and friends visit. But for the foreseeable future, I think that's a very big challenge. I think maintenance of PPE is also very important.


Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery?
Dr. Steven Wexner: I think that to protect both the patient and the hospital, that's the ideal approach, although it may not be feasible in every environment due to testing capabilities. However, in my opinion, it's the ideal scenario. And its purpose is two-fold. One is to protect healthcare workers, which includes preservation of PPE. So if we know that a patient is COVID-positive, we can decide whether to treat with full PPE or to defer treatment. If we proceed with treatment, the informed consent will include the data from the COVIDsurg study from the UK. Specifically, the postoperative mortality in a patient with COVID-19 was approximately 25 percent, which is vastly higher than standard postoperative mortality. This mortality was due to pulmonary complications from COVID-19; thus, if an asymptomatic patient is planning to undergo elective surgery and is found to be COVID-19 positive, it may be advisable to defer surgery to protect the patient as well as the healthcare staff. So yes, I do think testing is ideal.

Colleen: Do you think that laparoscopy should be used in patients with COVID-19?
Dr. Steven Wexner: I think if it's practiced very, very carefully, assiduous technique to no leakage of gas, and full PPE, then yes, as laparoscopy benefits patients. Furthermore, given the high postoperative mortality from pulmonary complications, avoiding pulmonary complications by avoiding a big laparotomy incision is probably the desirable endpoint, particularly in this patient population. Safety is of paramount importance to enable continued employment of the access method that best optimizes patient outcomes.


MISS E-News COVID Resource Center

ACS: American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery (for online access and a printer-friendly version:

SAGES: Impact of COVID-19 Pandemic on the Conduct of Surgical Research
A group of surgical leaders from affected countries have joined to discuss what they are learning during this crisis. Here is a brief summary:

Journal of the American College of Surgeons Article: Fibrinolysis Shutdown Correlates to Thromboembolic Events in Severe COVID-19 Infection
Pre-proof available online:

General Surgery News Article: Billing for COVID-19 Care—Getting Your 20% Medicare Add-on Payment for COVID-19

FDA Updates: Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions

ASGE: COVID-19 Practice Operations Discussion Forum: Lessons Learned from the Initial Phase of Resuming Endoscopy Services

ASGE: Services Guidance For Resuming GI Endoscopy And Practice Operations After The COVID-19 Pandemic

IBC Webinar: Covid-19 & Implications in Obesity, Diabetes, Metabolic & Cancer Surgery


Suggested Readings


Article: Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
Look AHEAD Research Group. N Engl J Med. 2013 Jul 11;369(2):145-54.
Dr. Steve Nissen: The Look Ahead study shows that lifestyle changes are not effective in severe obesity.



Article: Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database. Nasser H, Munie S, Kindel TL, Gould JC, Higgins RM. Surg Obes Relat Dis. 2019 Dec 3. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/31932204
Dr. Jaime Ponce: Another great article from the MBSAQIP database. It gives us a landscape of the utilization of different techniques in revisional bariatric surgery, with only 7.8% of the revisional cases being done robotically. Robotics has been suggested as a tool to deal with more complex cases, and this is one factor that we cannot extract from the MBSAQIP database. The potential bias for taking the more difficult revisional cases to a robotic platform may be a potential factor for the longer operative time and increased complications in the revisional sleeve gastrectomy cases. It is well known that longer and more complex cases can have increased morbidity. Interestingly, the use of robotics in revisional gastric bypass cases didn’t increase operative time or morbidity when compared to conventional laparoscopic technique. Robotics in my perspective is a tool that when used in the right hands can assist in performance of more complex revisional cases.


Vol. 8 No. 41


We are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. Last week we gave you key insights from MISS 2020 Faculty Dr. Neil Floch and Dr. Elizabeth Dovec on telehealth during COVID and its future expanding role, with a specific focus on its impact on bariatric practice. This week we hear from Hernia Program Co-Director Guy R. Voeller, MD, and MISS Colon Program Co-Director Bradley R. Davis, MD, on how COVID has impacted their hernia and colon surgery practices, how they are coping, and what restarting will look like.

We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center.

We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here. Stay safe and check back next week for more!


Colleen Hutchinson


Interview with Dr. Guy Voeller & Dr. Brad Davis

Colleen: How would you characterize the virus’s impact specific to your area of surgery?
Dr. Guy Voeller: The major impact on my area of surgery was a decrease in the number of elective cases. This has had a huge impact on most surgeons and their staffs. The ability for people to make a living and to care for their loved ones is one of the most distressing aspects of this entire mess and I can’t wait for things to ramp back up so our staff can work full time and provide for their families. Also, I think a lot of people will have lost their health insurance with the unemployment issue, and I think this will play a role in the elective surgery returning to pre-COVID levels.

Dr. Brad Davis: We were impacted, but we continued to perform surgery for cancer and symptomatic IBD. So our backlog was much less than those surgeons who were doing only truly elective cases – just as important but less time sensitive. The biggest impact was just on the workflow with no families and social support for the patients in the hospital; it is very hard for them.


Colleen: What will restarting your practice look like and how will it be different?
Dr. Guy Voeller: We started urgent elective surgery this week and next week I have 19 cases to do as surgeon and/or assistant. This is a little less than normal. The main difference and one of the more difficult things is my nurse has to coordinate having our patients getting a COVID test 48 hours before their surgery and then they have to quarantine etc. This will add a lot to logistics and things will fall through the cracks etc. until a routine can be established.

Dr. Brad Davis: Virtual care is here to stay. It is just too big a value added for the patient. Restarting will be great and we are prepared. Teamwork is the key with everyone working together to get the patients scheduled and taken care of safely.


Colleen: What has been the most surprising thing coming out of COVID19 that is positive, from your perspective?
Dr. Guy Voeller: For me personally, the most surprising and positive thing is how much I enjoyed the much lower stress level I experienced due to the forced downtime. After being a surgeon for over 30 years and keeping my head down charging ahead as we do as surgeons, you get so used to the stress level and you become very accustomed to this fact of life. I truly was surprised by and tremendously enjoyed the huge difference in my level of stress and will miss enjoying the daytime sunshine sitting on my patio. It will be very difficult to resume a busy schedule this coming week.

Dr. Brad Davis: The use of virtual care platforms and the value that virtual care creates for patients without sacrificing safety and outcomes.


Colleen: What has been the most challenging thing coming out of COVID19, from your perspective?
Dr. Brad Davis: The models were mostly wrong and it became clear that we just don’t have a good way to model the behavior of the virus as there are so many complexities – it’s basically chaos theory. You get one super spreader coughing in a busy park and you are overwhelmed. Otherwise, all the social distancing mostly kept patients out of the hospital and the ORs empty—lots of inactivity for the surgeons doing elective work despite the fact that we never needed the extra capacity. It is very challenging to thread the needle on what should and should not be done.

Dr. Guy Voeller: One of my sons needs a kidney transplant and my wife is the donor. Trying to determine when is the safest time for both of them to have a very serious operation and my son’s resultant immunosuppression during this viral outbreak has without question been the most challenging thing for me during this pandemic. We still have not made a decision due to all these issues.


MISS E-News COVID Resource Center

ASMBS: COVID-19 Updates: Restarting Surgery - Issues to Consider in Prioritizing Cases
Register here:

VIDEO: General Surgery News Residents’ Experience as a Resident During the COVID-19 Pandemic:

FDA Guidance Documents Related to Coronavirus Disease 2019 (COVID-19); Availability. Available at: https://www.federalregister.gov/documents/2020/05/12/2020-10146/guidance-documents-related-to-coronavirus-disease-2019-covid-19-availability

Surgical Endoscopy article: SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic

SAGES COVID-19 MEDICAL DEVICE REPOSITORY (inclusive of Commercially Available Smoke and Gas Evacuation Systems, N95 Facepiece Respirator Decontamination Systems, and COVID-19 Testing Products)

ACS Bulletin: ACS COVID-19 Update

Journal of the American College of Surgeons Article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic
Pre-proof available online:

Article: Surgeons, Ethics, and COVID-19: Early Lessons Learned


Suggested Readings


Article: Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease. Kirkham EN, Main BG, Jones KJB, Blazeby JM, Blencowe NS. Br J Surg. 2020 Jan;107(1):44-55.

Dr. Luke Funk: Magnetic sphincter augmentation (MSA) surgery has existed as a treatment for GERD for nearly a decade. Advocates of this procedure note that is does not involve significant distortion of the gastric or hiatal anatomy and creates a durable strengthening of the LES mechanism. In this study, the authors conducted a systematic review of the literature and included data from 39 studies. The investigators applied the “IDEAL Framework” for assessing innovative surgical procedures and concluded that most studies did not include important data regarding patient selection, surgical technique, or surgical outcomes. Nearly two-thirds of the studies were case series, and only 1 was an RCT. None included information about the learning curve for surgeons, and no single outcome was measured in all studies. These findings are notable because several thousand devices have been implanted thus far and many more will likely be implanted. Additional data collection and rigorously conducted prospective studies are needed so surgeons can better understand the short- and long-term risks, benefits and outcomes of this procedure.



Article: The True Story on Deficiencies After Sleeve Gastrectomy: Results of a Double-Blind RCT. Häuschen L, Schijns W, Ploeger N. Obes Surg. 2019 Nov 27.
[Epub ahead of print]

Dr. Dimitrios Pournaras: There has been a rapid rise in the popularity of sleeve gastrectomy in recent years and has now surpassed Roux en Y gastric bypass as the
most commonly performed procedure world-wide. A significant driver behind this trend is the widely held perception that it is not only quicker but a more simple operation from a technical perspective. Proponents of sleeve gastrectomy have also cited a lower likelihood of vitamin deficiencies compared to RYGB as one of its advantages. This study is a double blind RCT evaluating the use of multivitamin supplementation, specifically tailored for patients post sleeve gastrectomy. The findings of the study illustrate that not only do patients require supplementation post-sleeve gastrectomy, but needs are likely higher than previously thought.



Vol. 8 No. 40


As your trusted resource for all things surgery and COVID, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. The focus? Telehealth! This week, we provide you with key insights from MISS 2020 Faculty Dr. Neil Floch and Dr. Elizabeth Dovec, two surgeons who are considered major thought leaders in social media and related concepts. Here they share with you their thoughts on telehealth now during COVID challenges and its future expanding role in practice, with a specific focus on its impact on bariatric practice.
Since our goal is to keep you informed by giving you all the critical info in one place, we also providing the most current telehealth best practices resources in our new MISS E-News Resource Center.

We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here. Stay safe and check back next week for more!


Colleen Hutchinson

Interview with Dr. Elizabeth Dovec & Dr. Neil Floch

Colleen: Plato said: Necessity is the mother of invention. Right now, by necessity, virtual reality is creating more touch points with patients. We have seen telemedicine’s role in patient care and practice management grow exponentially during this pandemic.
What will this mean for patient compliance, patient outcomes, insurance requirements pre-and post-op, marketing, outcomes reporting, COE designation maintenance, and other outcomes reporting collaboratives?

Dr. Floch: In times of dire necessity during the COVID-19 outbreak, doctors were strongly discouraged from seeing patients in-person to limit their exposure to the virus. 1 The US government implemented two rules that allowed for the rapid adoption of telemedicine technology: 1) allowance to use non-HIPAA compliant telemedicine platforms 2,3 and 2) insurance coverage for virtual visits. 2,3

These changes have the potential to dramatically change multiple facets of bariatric surgery patient care. Live webinars could become more accessible and convenient for marketing programs and the education of the preoperative patient. Patient compliance with postoperative visits could become more convenient as patients may be seen in the evening, at a break during work, and while caring for their young children. As technology advances, the reliance of a patient weighing him/herself may evolve into texting pictures of the scale or using “smart scales” that link to a surgeon’s electronic medical record. Long-term outcomes may improve as patients become more compliant with telemedicine visits. Reporting for centers of excellence requirements may become easier to fulfill as patients become more compliant.

Dr. Dovec: While it took a global crisis for us to recognize the vulnerability of the outdated way we practice medicine, we now have an exceptional opportunity to incorporate technology into how we take care of patients. Currently, the pandemic has led to extensive limitations in surgical treatment of morbid obesity. Like the rest of the US healthcare industry, weight loss surgery (WLS) is structured on the historically necessary model of in-person interactions between patients and clinicians. Numerous variables hinder eligible people from seeking or progressing to surgery including lengthy, insurance mandated, preoperative, supervised weight loss.

Using these unusual times as a catalyst, embracing digital education platforms as a novel and necessary long-term solution in bariatric preoperative education is needed. This tool holds great potential for the resource-limited setting that will follow the peak of the coronavirus pandemic. In the context of bariatric preoperative education, this platform has demonstrated equivalent preoperative outcomes along with decreased attrition and time to surgery. Subjectively, participants found it to be convenient and easily understandable. Although a traditional, in-person supervised weight loss program is required by many insurance companies, digital options improve access for patients, standardize the material delivered, and decrease preoperative obstacles. Finally, it offers an evidence-based, validated alternative to relax these insurance requirements.
Colleen: What will “restarting” your surgical practice look like?
Dr. Floch: Restarting a surgery practice will begin with patients who are most in need of surgery. The most urgent cases will be identified and categorized as to their difficulty. Urgency will be defined as problems that are affecting their daily life. Relatively elective cases shall be performed next. Considerations shall be made to a patient’s medical conditions, such as diabetes, obesity, heart disease, lung disease, sleep apnea, immunity, kidney disease, and the risk of having COVID19. A recent paper describes a scoring system that can be used by hospital systems to determine when certain cases are safe to perform according to each institution’s unique situation. 6

Patients who have been living with symptoms from complications of bariatric surgery such as ulcers, severe reflux, obstruction, and related chronic diseases, such as symptomatic gallbladder disease and hernias, will be addressed first. As obesity is a chronic condition that affects many medical issues and the length of life, bariatric surgery is not elective since it dramatically improves the obesity condition and a patient’s future risk of mortality from COVID-19. When considering all bariatric patients, those who are prepared for surgery will proceed next, followed by patients who have time-sensitive requirements. Many patients may need to repeat some of these requirements unless insurers accept them because of the COVID-19 pandemic.
Dr. Dovec: “Restarting” in the operating room requires strategy. We have kept organized lists of patients that need to be scheduled. I have been doing outpatient gastric bypasses, sleeves, sleeve to bypass revisions, and band removals for months prior to the pandemic. The list of patients to be scheduled also includes who is a clinically acceptable outpatient surgery center candidate. The outpatient centers will be opened first for elective cases, and I plan to prioritize all my eligible cases there. I will remain in the outpatient setting until that volume of work is completed and then go back to the hospital. I’m hoping going back to the hospital several weeks after the other “elective” surgeons have started will give more OR time and resources to our bariatric patients. I also think patients will desire to go home as soon as possible and will not want to linger in a hospital setting.

Colleen: Will a shift to telemedicine for any parts of practice require a shift as well in document/materials management, access, and storage?
Dr. Floch: Telemedicine functions very similarly to live visits concerning documentation as all notes can be recorded in an electronic medical record. Although telemedicine visits are not regularly recorded, there is a future potential to record visits both for medico-legal reasons and as an educational tool for patients to refer back to their visits for information they may have missed.

Dr. Dovec: We will no longer have the need to give patients lengthy binders and store them in the office setting. All documents can be housed on the website for easy access and sent through their electronic medical records. We estimate saving $12,000 annually in printing fees alone.

We have long ago outgrown the physical space of our office. This has been rate-limiting in allowing us to grow beyond 1,300 cases performed annually. In addition to doing more surgeries by offering pre- and postoperative appointments virtually, this week we are launching a 100% virtual, comprehensive, postoperative medical weight loss program.
Colleen: What do you foresee as challenges we will encounter in the growing and future use of telemedicine?
Dr. Floch: Telemedicine will never replace a live visit and the need to see and examine a patient. Doctors must be able to palpate the abdomen to determine if a patient is tender from an acute appendix or gallbladder and must be able to examine a hernia especially one that may need to be reduced. Some forms of examination can be performed by telemedicine. Vital signs such as O2 saturation, heart rate, blood pressure, and weight may be obtainable by the patient and conveyed to the physician. Seeing the patient for the overall appearance of his/her organ systems is possible. Psychiatric and some neurologic evaluations may be possible by talking to the patient. In the future, patient participation, phone and computer applications, and devices may expand the capabilities of the telemedicine-physical exam. There is a learning curve with both patients and medical staff to adapt to technology. 1 There will be the challenges of HIPAA compliance and cyber-security to limit the potential breaches in personal information. 4

Dr. Dovec: I never stopped my bariatric surgical office practice. Our practice decided to go 100% virtual and pushed through the challenges of change. I doubled down on my digital marketing efforts to improve visibility and enhance existing patient engagement. Following the trends, we have seen a significant return on investment with an increase in the number of new patients starting their virtual journey. The importance of creatively keeping the pipeline of surgical candidates interested is high. We are not just surviving; we are thriving by changing the game instead of trying to play the same old one.
Colleen: How will telemedicine affect reimbursement (ie, coding, access to care, etc)?
Dr. Floch: There will always be a mix of live and virtual patients that compose a doctor’s practice. Currently, telemedicine may be reimbursed similar to normal visits or according to time of participation. Doctors must indicate in their notes that it is a telemedicine visit by audio and video. They must record how long the meeting was and what it entailed, indicate the start and end time, and add a consent to perform the visit with their identification number and indication that the patient agreed to a telemedicine visit. 5

Dr. Dovec: Social distancing has allowed some of the telemedicine billing and coding rules to be relaxed. The way you bill an in-person new patient or established CPT code is the same for a video visit. In place of the comprehensive physical exam, you will now bill for face-to-face time spent through counseling and the coordination of care. For example, incorporating the information session where you explain the risks, benefits, and alternatives to surgical treatment into the virtual initial consult as a live group session prior to the private video visit increases face time with the surgeon and increases billing and coding levels. Research shows that doctors spending more time with patients see better medical outcomes. When doctors take time to make human connections—or to be compassionate, patient outcomes improve and medical costs go down. The more satisfied that patients are with the care you provide, the more likely they will refer their friends and family to you.

Colleen: Time is money. And telemedicine increases access by breaking down barriers. What are the potential upsides for both the surgeon and patient with the use of telemedicine/virtual reality?

Dr. Floch: Telemedicine is a major advantage to practices that can increase patient visits and reduce costs. The patient won’t need to drive to the doctor, park, walk distances when they are impaired, or take time off from work. Doctors will need less staff to see patients and may need smaller offices. They may be able to share space, which will reduce real estate costs and overhead. There will be the possibility to work from home. There can be better access after regular business hours and on the weekends. There will be better documentation as phone and virtual visits will be documented in electronic medical records.

Dr. Dovec: There is mounting evidence that telemedicine can save patients and programs alike two things they value most: time and money. By simplifying the sign-up process, seeing patients on time for their initial consultation via video visit, providing online educational materials and support by connecting your patients with their peers on existing social media platforms, getting them set up with a standardized digital preoperative education platform (which often counts for the insurance-mandated preoperative requirements and offers free program patient tracking), doing the final preparation class and consultation virtually will all result in more patients having surgery. In summary, if we embrace telehealth now, we will undoubtedly lay the foundation to increase the 1%.


MISS E-News COVID Resource Center

ACS: New toolkit provides rapid implementation guide for adopting telemedicine during COVID-19

ASMBS Free Webinar—COVID-19 Updates: Embracing Telehealth

SAGES Free Webinar – Surgical Guidelines During COVID-19

Novel Coronavirus Information Center: Elsevier’s free health and medical research on the novel coronavirus (SARS-CoV-2) and COVID-19

General Surgery News Article: Preparing for Overwhelmed ICUs by Leveraging Existing ORs, Anesthesia Machines and Perioperative Personnel—A Call to Action


Suggested Readings and References from Dr. Neil Floch

1. Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program amidst the COVID-19 Pandemic. Journal of American College of Surgeons. DOI:
Dr. Floch: These are recommendations on how to start telemedicine in a practice.

2. Centers for Medicaid Services. Anon: Medicare Telemedicine Health Care Provider Fact Sheet.
Dr. Floch: This is information on telemedicine articles and government mandates associated with telemedicine.

3. Benefits in Medicare are a Lifeline for Patients During Coronavirus Outbreak | CMS.
Available at: https://www.cms.gov, accessed April 6, 2020.
Dr. Floch: This is information on Medicare and telemedicine.

4. Hakim D and Singer N: New York Attorney General Looks Into Zoom’s Privacy Practices. 2020.
Dr. Floch: The Zoom application and potential patient privacy issues.

5. General Provider Telehealth and Telemedicine Tool Kit
Dr. Floch: Extensive information, all pertinent to telemedicine.

6. Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. Prachand VN, Milner R, Angelos P, et al. J Am Coll Surg. 2020;S1072-7515(20)30317-3.
Dr. Floch: An article detailing how hospital systems can restart elective surgery after COVID19.



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